Pike, Ruth TOWN OF QUEENSBURY
Pine View Cemetery and Crentntorium
21 Qunker Road, Queensbury, NY. 12804-5902
(518) 745-4476 (518) 745.4477
http //www.queensbury.net
Funeral Director:
Name of Deceased: �� :�2 L K
Case Number: 7 2 G
Date of Cremation: ! — (e- —
Retort: i
Time Cremation Started: �� ` t
Time Cremation Completed:
Type of Container: �ll�l ��✓�-�2 la LI
Remarks:
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" Home of Nntural Benitty ... A Cood Plnie to Ltue "
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_' Town of Queensbury
Pine View Cemetery
Crematorium
Quaker Road, Queensbury, New York 12804
phone(518)Crematorium 745-4477(if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject
to' Rules and Regulations to cremate the remains of:
Name Sex
1--)"M 4' a-dic,
Street City State Zip
who died on day of J y L 20 O J
at -)I Q.,''?S F& I IS AOS DI+6
place Address
Name and address of nearest living relative or name of person authorizing cremation
IA I l I t C1 j,, PI ke. I Z 'RD 11 Md4 Od L :dOA let., 0 1Z 93S
Relationship to deceased •':�I111
Name of Funeral Home BREWER FUNERAL HOME, INC.
IMPORTANT
I represent that to the best of my knowledge,the deceased has has no pacemaker i is or her body(CIRCLE ONE)
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition
of the cremated remains,that any personal possessions have either been removed or may be destroyed,and agree
to protect,defend and save harmless Pine View Crematorium from any and all claims and demands for loss or damag(s or dam-
ages which m;a made again t them by reason of or connected with the cremation of said remains as directed,whether ed,
whet. ch claims or are not dly groundless,false or fraudulent.
r
Witness Address
/C r
(SIGNATURE OF RELATIVE OR LEGAL REPRES TITIVE)
signed on this date 5 �i
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